The localisation of precisely where pain is coming from in the pelvis and abdomen is equally as difficult for the patient as it is for the doctor to ascertain. Therefore, there are several multidisciplinary conditions that can cause chronic pelvic pain and cause overlapping similar symptoms. Urological causes include renal stones or interstitial cystitis. Gastroenterological causes include functional bowel disorders like IBS, or inflammatory bowel disease. Cyclical pain tends to suggest a gynaecological cause and a possible endometriosis diagnosis. All of these pains tend to be pains of a visceral type that cause fatigue, heaviness, dragging and aching and even nausea & vomiting. The other type of pain is somatic pain and this tends to be neurological in origin and be stabbing, erratic, electrical sensations with numbness, pins and needles sensations and sometimes altered bowel, urinary or sexual function. These need specialised diagnosis and management. Muscle spasm related pain may cause deep or superficial vaginal pain and may benefit from specialised pelvic floor manipulation offered by a variety of subspecialties. Central sensitisation pain syndromes may benefit from psychological input and counselling.
Because of this potential variation in diagnoses a full assessment is crucial to guide the endometriosis specialist towards the most likely causes of pain in each particular woman's case. This sometimes requires the input of other experts in their fields. At The Endometriosis Clinic we have gathered a range of such experts to refer onto for second opinions and assistance in care.
This is perhaps the most crucial part of the assessment and is as important in what it excludes as what it finds. With a detailed expert scan prior to consultation we can proceed to a meaningful discussion immediately about treatment. This requires an expert level of scanning, and for this reason we do not do our own scans and instead send women to the Gynaecology Ultrasound Centre (http://www.ultragyn.co.uk) in Harley Street for scanning by Mr Davor Jurkovic or one of his team of experts in gynaecological and endometriosis scanning. This is one of the world's leading centres. With the information from these scans we can reliably decide upon whether simple or complex surgery is an option, drug therapy or whether you may need a referral to another specialist.
Women who are suspected of having somatic neurological pain need expert assessment by a specialist in neurological pelvic pain. These specialists are rare to find as most pain clinics are quite generic and formulaic in their approach and generally involves trial of neuromodulation drugs like Gabapentin and Duloxetine without deeper investigation into the exact underlying cause. We may refer to Dr Andrew Baranowski who practises at The National Hospital for Neurology and Neurosurgery at Queens Square, and has a private practice close to our clinic (http://www.apbuk.net). Detailed assessments may include high resolution MR Neurography, electrical conduction studies, nerve blocks and neuromodulation, referral on for physiotherapy and psychological intervention, and sometimes referral back to us for consideration of specialist neurosurgical intervention either in UK or by referral onto an expert in Switzerland.
We see a number of European women with recurrent miscarriage problems who have been recommended to have surgery by Dr Jeffrey Braverman (sadly deceased), who was the founder and director of Braverman IVF & Reproductive Immunology in New York City, USA (http://www.preventmiscarriage.com/about-us.html), and we also may refer women to this clinic for complex fertility issues.
Women who wish to remain more local, or who have less complex issues, we tend to refer to The Lister Fertility Clinic in London (https://ivf.org.uk).
Some women may wish to consider egg or embryo freezing prior to any endometriosis surgery so they have a back up plan as there is a small risk of significant ovarian damage in the presence of endometriomas and poor ovarian reserve results.
We often do not need to perform MRI scans as we have access to excellent ultrasound services. However sometimes we need to review MRI scans that women have had done in other centres and there may be a charge for this. If we do need to perform an MRI then we use Dr Priya Narayanan, an expert radiologist in nerve and endometriosis MRI (.https://www.hcahealthcare.co.uk/consultants/d/dr-priya-narayanan).
Also, we sometimes have women with coexisting or separate uterine fibroid problems (uterine myomas). These need MRI assessment on occasions, especially if the patient is considering uterine artery embolisation as a treatment option (UAE) as well as possible surgical removal of fibroids. For such cases, we refer to Dr Woodruff Walker, one of the world’s leading exponents of uterine artery embolisation, and an expert in MRI for deep infiltrating endometriosis (http://fibroids.co.uk).
Colorectal and Gastroenterology
With severe cases of deep infiltrating endometriosis the rectum and/or sigmoid colon are often also involved in the pelvis. Most cases we can manage by shaving endometriosis from the bowel surface without the need for opening the bowel. Occasionally we require the assistance of a colorectal surgeon during complex operations and expert cover is provided for us by Mr Edward Westcott (http://www.londonbridgehospital.com/LBH/consultant-det/mr-edward-d-a-westcott/). Also, if we predict that the chances of needing a bowel procedure are higher than normal then we will arrange for you to meet Mr Westcott before surgery to discuss this.
Sometimes we require urological support in complex operations to insert stents into the ureters to protect them against leaks, or to re-implant ureters into the bladder if it is not possible to save them. The Princess Grace Hospital has numerous expert urological surgeons as it is one of the country’s leading centres for urological robotic surgery, with experts easily available for support.
Bladder pain syndromes like interstitial cystitis are difficult to diagnose and manage and so they need an expert with a true interest in this area. We refer our patients requiring a fuller bladder assessment on to Mr Rizwan Hamid at London Urology Associates, who also practises at The Princess Grace Hospital (http://www.lua.co.uk/the-urology-team/members/rizwan-hamid/)
If women undergo surgery that involves removing both ovaries, or experience ovarian failure, then they will become menopausal soon after. In the initial phases we manage this ourselves with continuous combined (Oestrogen and Progesterone) Hormone Replacement Therapy to reduce the risk of endometriosis recurrence. Sometimes women need a greater level of expertise to fine tune this and are then referred on to see Miss Claudine Domoney (http://www.thelisterhospital.com/consultant-search/ms-claudine-domoney/).